Basic Information
| Provider Information | |||||||||
| NPI: | 1043207764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRUSKA | ||||||||
| FirstName: | MYRON | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2240 REMOUNT RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046715311 | ||||||||
| FaxNumber: | 7046715308 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 PARK ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BELMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280125205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048254750 | ||||||||
| FaxNumber: | 7048256985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9600678 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | N00678 | 05 | SC | MEDICAID | 8967080 | 05 | NC | MEDICAID |